Nokea
Which of the following examples of nursing actions involve direct care of the patient? Select all that apply.
- A. A nurse counsels a young family who is interested in natural family planning.
- B. A nurse massages the back of a patient while performing a skin assessment.
- C. A nurse arranges for a consultation for a patient who has no health insurance.
- D. A nurse helps a patient in hospice fill out a living will form.
- E. A nurse arranges for physical therapy for a patient who had a stroke.
- F. A nurse comforts a distraught patient whose baby was stillborn.
Correct Answer: A,B,D,F
Rationale: Direct care involves hands-on or face-to-face interaction with the patient. Counseling (A), massaging (B), assisting with a living will (D), and comforting (F) involve direct patient interaction, whereas arranging consultations (C) and physical therapy (E) are indirect care activities.
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A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean?
- A. The nurse is using critical thinking to implement the dressing change.
- B. The patient has specified how the dressing should be changed.
- C. Written plans are developed that specify nursing activities for this skill.
- D. The physician verbally requested specific steps of the dressing change.
Correct Answer: C
Rationale: An established protocol means written plans specify the nursing activities for the procedure, ensuring standardized and evidence-based practice.
A student is ambulating a patient for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome?
- A. Take the patients vital signs after ambulation.
- B. Ask the patients wife to assist with ambulation.
- C. Delay ambulation until the following shift.
- D. Ask another student to help with ambulation.
Correct Answer: D
Rationale: Asking another student to help anticipates potential complications (e.g., falls) by ensuring additional support is available during ambulation.
What is the unique focus of nursing implementation?
- A. patient response to health and illness
- B. patient response to nursing diagnosis
- C. patient compliance with treatment regimen
- D. patient interview and physical assessment
Correct Answer: A
Rationale: The unique focus of nursing implementation is addressing the patient's response to health and illness, as it involves carrying out interventions to promote health, prevent illness, or manage health problems.
A patient who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?
- A. to implement evidence-based practice
- B. to ensure the order follows hospital policy
- C. to be sure interventions are individualized
- D. to be sure the intervention is safe
Correct Answer: D
Rationale: The nurse reviews the plan to ensure the intervention (increasing oral intake) is safe, as an unconscious patient cannot safely consume oral intake, risking aspiration.
What core value of nursing care is missing when a nursing intervention is delegated to a UAP?
- A. communication
- B. patient teaching
- C. nurse/patient dynamic
- D. competent care
Correct Answer: C
Rationale: Delegating to a UAP may miss the nurse/patient dynamic, as the professional relationship and holistic assessment provided by the nurse are not fully replicated.